Penn Family Medicine Residency

 

Gyn Visit (Safiyya Shabazz)

Page history last edited by Richard 2 yrs ago
SUBJECTIVE:Pt . is a .age G***P*** female who is here for gyn exam. .lmp . Pt uses *** for contraception. She is *** satisfied with this method. Her periods are ***regular every 28-30 days, lasting 4-5 days. Her bleeding is typically ***. Pt has *** prior h/o STDs. Pt *** do regular breast self exams. She has *** noted any abnormalities and has *** history of abnormal mammograms. She has *** history of abnormal Pap smears *** .

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.ros *** vaginal discharge, *** abdominal pain, *** dysuria

OBJECTIVE:.vs

General appearance: alert, in no distress

Skin: Skin color, texture, turgor normal. No rashes or lesions.

Breasts: inspection and palpation negative, no nipple discharge or bleeding

Abdomen: Abdomen soft, non-tender. BS normal. No masses, organomegaly

Pelvic: External genitalia & vagina normal. Bimanual exam revealed no adnexal masses or uterine enlargement.

Wet Prep: *** clue cells, *** yeast, *** trichomonads

Assessment/Plan:

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